Surgical Endoscopy

, 25:3414 | Cite as

The Cross-technique for single-incision pediatric endosurgical pyloromyotomy

  • Oliver J. MuenstererEmail author
  • Albert J. Chong
  • Keith E. Georgeson
  • Carroll M. Harmon
Dynamic Manuscript



Single-incision pediatric endosurgical (SIPES) pyloromyotomy is frequently used for the treatment of hypertrophic pyloric stenosis at our center. Our initial SIPES approach mirrored the conventional, triangulated laparoscopic pyloromyotomy. Because an increased number of perforations were noted on our initial analysis, a more straightforward Cross-technique SIPES pyloromyotomy was developed. This study compares the current Cross-technique SIPES pyloromyotomy to the previous standard SIPES operation.


The Cross-technique entails grasping the antrum with the surgeon’s left hand instrument, retracting toward the left lower quadrant, and thereby orienting the pylorus obliquely toward the right upper quadrant. The serosal incision and muscular spreading is accomplished using a right-hand instrument that crosses over the left hand grasper. Demographic variables, operative times, estimated blood loss (EBL), complications, conversion rate, and postoperative length of stay were compared.


Twenty-nine Cross-technique patients were compared with 23 in the standard group. The Cross-technique was faster than the standard procedure (21 ± 5 vs. 27 ± 12 min, p = 0.03) and EBL was lower (1.3 ± 0.5 vs. 1.7 ± 0.6 ml, p = 0.02). There were two mucosal perforations requiring conversions to triangulated 3-access-site laparoscopy in the standard, and one conversion to open surgery in the Cross-technique group. Patients who underwent cross-technique pyloromyotomy weighed less (3.6 ± 0.6 vs. 4.0 ± 0.5 kg, p = 0.012), but there were no differences in age, gender ratio, conversion rate, or length of stay. There was one postoperative wound infection in the cross-technique, but none in the standard group. No patients required reoperation. All participating surgeons felt that the cross-technique was more ergonomic and easier to perform than the standard SIPES technique.


The Cross-technique appears superior to standard SIPES pyloromyotomy and should be preferentially used for single-incision endosurgical pyloromyotomy for hypertrophic pyloric stenosis.


Single-incision Laparoscopy Pyloromyotomy Infant Cross-technique 



Drs. Muensterer, Chong, Georgeson and Harmon have no conflicts of interest or financial ties to disclose.

Supplementary material

Video 1

Description of Cross-technique SIPES pyloromyotomy (WMV 5638 kb)

Video 2

Alternative use of the paddle-tip electrocautery to perform the serosal incision (WMV 2239 kb)

Video 3

Postoperative outcome 2 to 3 weeks after the procedure (WMV 2356 kb)


  1. 1.
    Muensterer OJ, Adibe OO, Harmon CM, Chong A, Hansen EN, Bartle D, Georgeson KE (2010) Single-incision laparoscopic pyloromyotomy: initial experience. Surg Endosc 24:1589–1593PubMedCrossRefGoogle Scholar
  2. 2.
    Muensterer OJ (2010) Single-incision pediatric endosurgical (SIPES) versus conventional laparoscopic pyloromyotomy: a single-surgeon experience. J Gastrointest Surg 14:965–968PubMedCrossRefGoogle Scholar
  3. 3.
    Haricharan RN, Aprahamian CJ, Morgan TL, Harmon CM, Georgeson KE, Barnhart DC (2008) Smaller scars—what is the big deal: a survey of the perceived value of laparoscopic pyloromyotomy. J Pediatr Surg 43:92–96PubMedCrossRefGoogle Scholar
  4. 4.
    Yagmurlu A, Barnhart DC, Vernon A, Georgeson KE, Harmon CM (2004) Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series. J Pediatr Surg 39:292–296PubMedCrossRefGoogle Scholar
  5. 5.
    Hall NJ, Ade-Ajayi N, Al-Roubaie J, Curry J, Kiely EM, Pierro A (2004) Retrospective comparison of open versus laparoscopic pyloromyotomy. Br J Surg 91:1325–1329PubMedCrossRefGoogle Scholar
  6. 6.
    Adibe OO, Nichol PF, Flake AW, Mattei P (2006) Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital. J Pediatr Surg 41:1676–1678PubMedCrossRefGoogle Scholar
  7. 7.
    Lange R, Rey M, Fernández ED (2008) Open vs. laparoscopic pyloromyotomy—a retrospective analysis. Minim Invasive Ther Allied Technol 17:313–317PubMedCrossRefGoogle Scholar
  8. 8.
    St Peter SD, Holcomb GW 3rd, Calkins CM, Murphy JP, Andrews WS, Sharp RJ, Snyder CL, Ostlie DJ (2006) Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 244:363–370PubMedGoogle Scholar
  9. 9.
    Leclair MD, Plattner V, Mirallie E, Lejus C, Nguyen JM, Podevin G, Heloury Y (2007) Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. J Pediatr Surg 42:692–698PubMedCrossRefGoogle Scholar
  10. 10.
    Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A, Langer JC, Koivusalo AI, Pakarinen MP, Stroedter L, Beyerlein S, Haddad M, Clarke S, Ford H, Pierro A (2009) Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 373:390–398PubMedCrossRefGoogle Scholar
  11. 11.
    Hall NJ, Van Der Zee J, Tan HL, Pierro A (2004) Meta-analysis of laparoscopic versus open pyloromyotomy. Ann Surg 240:774–778PubMedCrossRefGoogle Scholar
  12. 12.
    Sola JE, Neville HL (2009) Laparoscopic vs open pyloromyotomy: a systematic review and meta-analysis. J Pediatr Surg 44:1631–1637PubMedCrossRefGoogle Scholar
  13. 13.
    Jia WQ, Tian JH, Yang KH, Ma B, Liu YL, Zhang P, Li RJ, Jia RH (2010) Open versus laparoscopic pyloromyotomy for pyloric stenosis: a meta-analysis of randomized controlled trials. Eur J Pediatr Surg [Epub ahead of print]. doi: 10.1055/s-0030-1261926
  14. 14.
    Ford WD, Crameri JA, Holland AJ (1997) The learning curve for laparoscopic pyloromyotomy. J Pediatr Surg 32:552–554PubMedCrossRefGoogle Scholar
  15. 15.
    Kim SS, Lau ST, Lee SL, Waldhausen JH (2005) The learning curve associated with laparoscopic pyloromyotomy. J Laparoendosc Adv Surg Tech A 15:474–477PubMedCrossRefGoogle Scholar
  16. 16.
    Oomen MW, Hoekstra LT, Bakx R, Heij HA (2010) Learning curves for pediatric laparoscopy: how many operations are enough? The Amsterdam experience with laparoscopic pyloromyotomy. Surg Endosc 24:1829–1833PubMedCrossRefGoogle Scholar
  17. 17.
    Lazar D, Naik B, Fitch ME, Nuchtern JG, Brandt ML (2008) Transumbilical pyloromyotomy with umbilicoplasty provides ease of access and excellent cosmetic results. J Pediatr Surg 43:1408–1410PubMedCrossRefGoogle Scholar
  18. 18.
    Emil S (2009) Pyloromyotomy through an infra-umbilical incision: open technique and superb cosmesis. Eur J Pediatr Surg 19:72–75PubMedCrossRefGoogle Scholar
  19. 19.
    Kim SS, Lau ST, Lee SL, Schaller R Jr, Healey PJ, Ledbetter DJ, Sawin RS, Waldhausen JH (2005) Pyloromyotomy: a comparison of laparoscopic, circumumbilical, and right upper quadrant operative techniques. J Am Coll Surg 201:66–70PubMedCrossRefGoogle Scholar
  20. 20.
    Leinwand MJ, Shaul DB, Anderson KD (1999) The umbilical fold approach to pyloromyotomy: is it a safe alternative to the right upper-quadrant approach? J Am Coll Surg 189:362–367PubMedCrossRefGoogle Scholar
  21. 21.
    Ladd AP, Nemeth SA, Kirincich AN, Scherer LR 3rd, Engum SA, Rescorla FJ, West KW, Rouse TM, Billmire DF, Grosfeld JL (2005) Supraumbilical pyloromyotomy: a unique indication for antimicrobial prophylaxis. J Pediatr Surg 40:974–977PubMedCrossRefGoogle Scholar
  22. 22.
    Gauderer MW (2008) Experience with a nonlaparoscopic, transumbilical, intracavitary pyloromyotomy. J Pediatr Surg 43:884–888PubMedCrossRefGoogle Scholar
  23. 23.
    Perger L, Fuchs JR, Komidar L, Mooney DP (2009) Impact of surgical approach on outcome in 622 consecutive pyloromyotomies at a pediatric teaching institution. J Pediatr Surg 44:2119–2125PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Oliver J. Muensterer
    • 1
    • 2
    Email author
  • Albert J. Chong
    • 1
  • Keith E. Georgeson
    • 1
  • Carroll M. Harmon
    • 1
  1. 1.Division of Pediatric Surgery, Department of SurgeryChildren’s Hospital of Alabama, University of Alabama at BirminghamBirminghamUSA
  2. 2.Division of Pediatric SurgeryWeill Cornell Medical CollegeNew YorkUSA

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